Development and evaluation of an objective laparoscopic assessment tool: LapPass®.

INTRODUCTION: Laparoscopic surgery is technically challenging and assessment of competency is necessary to ensure patient safety and guide training. We report on the development of LapPass®, an accessible objective simulation assessment tool with credentialing potential. We provide a preliminary evaluation of its usability and aspects of validity. METHODS: The domains of LapPass® were defined through a consensus process by the executive council of the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). A survey of both assessors and trainees was used to test for usability, face and content validity of LapPass®. Internal consistency was tested with Cronbach's alpha, and a composite marker of validity and usability was obtained. RESULTS: LapPass® was developed to consist of four tasks: (1) grasping and manipulation, (2) simulated appendicectomy, (3) cutting a disk and (4) intracorporeal suturing. A total of 76 participants contributed to the evaluation of LapPass®: 13 assessors and 63 trainees. For assessors, Cronbach's alpha for usability of tasks 1-4 was 0.84, 0.84, 0.76 and 0.86, whereas validity was 0.80, 0.85, 0.88, 0.95, respectively. For trainees, Cronbach's alpha was 0.75, 0.77, 0.80 and 0.85 for usability, and 0.79, 093, 0.87 and 0.91 for validity. Consensus was that each task was usable and had face and content validity, with median scores of 4.0 or higher (interquartile range 0.0-1.0). CONCLUSION: LapPass® has potential for the objective assessment of basic laparoscopic skills but further research is required to explore its predictive capabilities in a clinical setting.

Are Type and Screen Samples Routinely Necessary Before Laparoscopic Cholecystectomy?

AIMS: Type and screen (T&S) samples are routinely requested before all laparoscopic cholecystectomies (LCs) at our centre despite the low reported risk of major vascular injury and peri-operative transfusion. Our retrospective case series aimed to identify local transfusion need to inform policy. METHODS: Emergency and elective LC performed at a single tertiary centre between March 2014 and October 2016 (30 months) were analysed. This included all patients aged ≥ 16, and procedures converted to open where LC was the primary procedure. Peri-operative complications and transfusion data were obtained from electronic records. RESULTS: In total, 1002 consecutive patients met inclusion criteria; 12 patients were transfused during index admission (1.20%). No patients required emergency transfusion or had major vascular injuries. Despite local policy, 106 patients (10.6%) did not have a valid T&S sample prior to their procedure. Transfused patients were more likely to be emergency admissions (n = 10/12). The most common indications for transfusion were pre-operative anaemia (n = 7/12) and septic coagulopathy (n = 2/12). CONCLUSIONS: Peri-operative transfusions at our centre were low. No patients required intra-operative blood transfusions dependent on a pre-operative T&S sample. Patients requiring transfusion were predictable from their pre-operative clinical status. We propose that a highly selective T&S policy is safe and can reduce costs.

Uniformity of stratum-ventilated thermal environment and thermal sensation.

Three human test series were conducted to evaluate the uniformity of the thermal environments in a stratum-ventilated chamber with dimensions of 8.8 m (L) × 5.1 m (W) × 2.4 m (H). In all, nineteen conditions were generated by adjusting the room temperature, supply airflow rate, and supply terminal type. An air diffuser performance index (ADPI) of at least 80% was achieved for most cases. This result shows that the air velocity and temperature in the occupied zone are reasonably uniform. Subjective assessments using the ASHRAE 7-point scale indicate that the thermal sensations of the subjects in stratum ventilation are also uniform. This study examines the applicability of the predicted mean vote (PMV) model for evaluating stratum ventilation. When compared to the actual mean thermal sensation votes (ATS), the PMV values are acceptable. The PMV results at a height of 1.1 m above the floor show better agreement with the ATS than at a height of 0.1 m.

Evaluation of thermal comfort conditions in a classroom with three ventilation methods.

UNLABELLED: Thermal sensation is studied experimentally under mixing ventilation, displacement ventilation, and stratum ventilation in an environmental chamber. Forty-eight subjects participated in all tests under the same boundary conditions but different ventilation methods in the classroom. Thermal comfort analysis was carried out according to the designated supply airflow rate, room temperature, and relative humidity for the three ventilation methods. The thermal neutral temperature under stratum ventilation is approximately 2.5 °C higher than that under mixing ventilation and 2.0 °C higher than that under displacement ventilation. This result indicates that stratum ventilation could provide satisfactory thermal comfort level to rooms of temperature up to 27 °C. The energy saving attributable to less ventilation load alone is around 12% compared with mixing ventilation and 9% compared with displacement ventilation. PRACTICAL IMPLICATIONS: The confirmation of the significantly elevated thermal neutral temperature can have a number of implications for both thermal comfort in an air-conditioned room and energy consumption of the associate air-conditioning system. With respect to the former, it provides scientific basis for the feasibility of elevated room temperatures, and with respect to the latter, it reveals considerable potentials for energy saving.

Measuring outcomes in psychiatry: an inpatient model.

BACKGROUND: This article describes a system for measuring outcomes recently implemented in the department of psychiatry of Baptist Memorial Hospital, a 78-bed inpatient and day treatment unit that represents one service line of a large, urban teaching hospital in Memphis. In June 1993 Baptist Hospital began a 15-month pilot test of PsychSentinel, a measurement tool developed by researchers in the Department of Community Medicine at the University of Connecticut. The hospital identified the following four primary goals for this pilot project: provide data for internal hospital program evaluation, provide data for external marketing in a managed care environment, satisfy requirements of the Joint Commission on Accreditation of Health Care Organizations, and generate studies that add to the literature in psychiatry and psychology. DESCRIPTION OF MEASURE: PsychSentinel is based on the standardized diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). The outcome measure assesses the change in the number of symptoms of psychopathology that occurs between admission and discharge from the hospital. Included in the nonproprietary system are risk adjustment factors, as well as access to a national reference database for comparative analysis purposes. Data collection can be done by trained ancillary staff members, with as much or as little direct physician involvement as desired. The system has proven to be both time effective and cost effective, and it provides important outcome information both at the program level and at the clinician level. RESULTS: After the pilot test, the staff at Baptist Memorial Hospital determined that the system met all initial objectives identified and recently adopted the system as an ongoing measure of quality patient care in the department of psychiatry.

Travel at low energetic cost by swimming and wave-riding bottlenose dolphins.

Over the past 50 years there has been much speculation about the energetic cost of swimming and wave-riding by dolphins. When aligned properly in front of the bow of moving ships in the stern wake of small boats, on wind waves, and even in the wake of larger cetaceans, the animals appear to move effortlessly through the water without the benefit of propulsive strokes by the flukes. Theoretically, body streamlining as well as other anatomical and behavioural adaptations contribute to low transport costs in these animals. The economy of movement permitted by wave-riding has been perceived as an energetic advantage for the swimming dolphin, but has been hard to prove in the absence of physiological data for exercising cetaceans. Here we determine the aerobic and anaerobic costs of swimming and wave-riding in bottlenose dolphins and find that the minimum cost of transport for swimming dolphins is 1.29 +/- 0.05 J kg-1 m-1 at a cruising speed of 2.1 m s-1. Aerobic costs are nearly twice as high for swimming seals and sea lions, and 8-12 times higher for human swimmers. Wave-riding by dolphins provides additional benefits in terms of speed. The results indicate that behavioural, physiological and morphological factors make swimming an economical form of high-speed travel for dolphins.